2 HomeostasisHomeostasis: processes that occur quickly in response to stress – adjustments made rapidly to maintain internal environment.Adaptation: processes resulting in structural or functional changes over time. This is a desired goal.Coping: a compensatory mechanism so that a person can reach equilibrium.
3 StressA state produced by change in the environment that is threatening or damaging
5 The S&S of StressWrite down at least 10Paste in table from page 87
6 Nursing CareIntervene when individual’s own compensatory processes are still functioning.Relate S&S of distress to physiological happenings.Identify person’s position on a continuum of function from wellness/compensation to pathophysiology/disease.
7 Stress at the Cellular Level Individual cells may cease to function without posing threat to the organism; however as the number of dead cells increases, the specialized function of the tissue is altered – health is threatened.
8 Nursing Care Assess S&S for indicators of physiologic processes. Relate symptoms/complaints to physical signs.Assist individual to respond to stress with stress management.
11 Preventing and Correcting FVD Who’s at risk?ReplacementOralEnteralParenteral
12 Fluid Volume Excess (FVE) Hypervolemia Weight gainEdemaAbnormal lung soundsIncreased urine outputPuffy eyelidsDistended neck veinsTachycardiaIncreased BP and pulse pressure.
13 Nursing Care Monitor I & O Daily weight Assess lung sounds Check edema: degree of pittingmeasure extremities.
14 Preventing and Correcting FVE Promote rest: favours diuresis and increases circulation (lower)Na+ and fluid intake restrictionsMonitor parenteral fluidsPositioning
15 Edema Localized or generalized Occurs when there is a change in capillary memberANASARCA: severe generalized edemaASCITES: edema in peritoneal cavityDependent area: ankles, feet, sacrum, scrotum, periorbital regionsPulmonary edema: increased fluid in pulmonary interstitium and alveoli
16 Electrolytes Sodium Normal 135-145mmol/L Potassium Normal 3.5-5mmol/L CalciumNormal mmol/L
17 Sodium: Hyponatremia At Risk Loss of Na Dilution of Na Nursing Care: Monitor I&ODaily weightEncouraging foods high in Na (normal requirement 500mg)Fluid restriction:800ml/dayClinical Manifestations:Anorexia, muscle cramps, exhaustion.Poor skin turgor, dry mucosa/skinConfusion, headacheThose at risk for hyponatremia are those losing sodium and those diluting their sodium – it’s all about concentration. Sodium can be lost through loss of GI fluids or diuretics. Water intoxication can result from inappropriate antidiuretic hormone. The signs and symptoms depend on the severity of hyponatremia and also the speed in which sodium concentration decreases.Nursing Care: Close monitoring of intake and ouptu is critical. In addition, daily weights are an accurate indicator of fluid retention or loss – normal variance day to day is less than 5%. If the low sodium is due to sodium loss rather than dilution – sodium can usually be replaced through regular diet with attention to mg na . If hyponatremia is due to dilution, then water restriction may be necessary. Restricting fluid intake is safer then administering sodium.
18 Sodium: Hypernatremia At RiskLoss of waterGain of sodiumNursing CareI&ONo added salt dietMonitor meds high in NaIf IV hypotonic solution used -- want gradual decrease in serum Na 9prevent cerebral edemaClinical ManifestationsThirst, dry mouthRestlessness, disorientationEdemaIncreased BP
19 Potassium: Hypokalemia Nursing CareECG for flattened T-waveID causeDiet – high KTeaching – use of diuretics, laxativesIV K replacementAt RiskVomiting/gastric suctioningAlcoholics/cirrhosisAnorexia nervosaNon-K sparing diureticsWith IV potassiuim replacement – infusion must be slow – achieved through dilution and rate of 100ml or less – 40mEq/1000ml – burns at site. If output goes less than 20ml/hr for 2 hours infusion should be stoppedFoods rich in potassium: Daily requirement 2000mg – baked potato with skin is 844mg – banana is 500mgClinical ManifestationsMuscle weakness, fatigue, anorexia, N&V, leg cramps, dysrrythmia
20 Potassium: Hyperkalemia At RiskKidney diseaseAddison’s diseaseExtreme tissue traumaK replacementNursing CareVerify high serum levelsRestrict K foodsTeaching re K supplementsNote: prolonged use of tournique when drawing blood can give false high potassium readings – therefore important to varify findings of highKeep in mind that 98% of K is ICF, and 2% in ECFClinical ManifestationVentricular dysrrhythmia, muscle weakness, peaked t-wavwes, respiratory paralysis
21 Calcium:Hypocalcemia Nursing CareSeizure precautionsAirway statusNutritional intake and supplementsLimit alcohol and caffeineAt RiskRenal failurePostmenopausalLow Vit D consumptionAntacids, caffeineHypoparathyroidismCalcium: adequate calcium absorption depends on availability of Vit D from diet or synthesis in skin (sunlight)Calcium requirements 800mg per day Milk 250ml is 300 mg ½ cup broccoli is 90mgClinical manifestationsTetany, seizures, depression,impaired memory, confusion
22 Calcium: Hypercalcemia Nursing careIncrease activityEncourage fluidsEncourage fluids Na – favour Ca excretionSafety/comfortAt RiskHyperparathyriodismBone/mineral loss during inactivityThiazide diureticsClinical ManifestationsReduced neuromuscular activity, weakness, incoordination, anorexia, constipation
23 Respiratory Acidosis Individuals at risk Clinical Manifestations Inadequate excretion of carbon dioxideChronic emphysema, bronchitisObstructive sleep apneaObesityClinical ManifestationsIncreased cerebrovascular flow (vasodilation) Increased pulse, respirations and BPMental cloudiness, feelings of fullness in head
26 Respiratory Alkalosis Nursing CareRecycle carbon dioxideTreat underlying cause
27 ShockPhysiological state in which there is inadequate blood flow to tissues and cells of bodyCells try to produce energy anaerobicallyLeads to low energy yield and acidotic intracellular environment
28 Categories of ShockHypovolemicCardiogenicCirculatory/Distributory
29 Stages of Shock Compensatory Progressive Irreversible While there are three categories of shock, there are three primary stages of shock which are common to all categories.
30 Compensatory Stage BP normal Vasoconstriction Fight or flight Increased HRIncreased contractilityBlood shunted to heart and brain.During this stage the body is trying to right itself.
31 Nursing Care in Compensatory Stage Close assessment and catch subtle changes before decrease in BP occursMonitor tissue perfusion.Report deviations in hemodynamic statusReduce anxietyPromote safetyTissue perfusion: vital signs, level of consciousness, outputDeviations in hemodynamic status – vital signs – suble changes in BP – decrease pulse pressure
32 Progressive Stage: Mechanism for regulating BP no longer compensates Respiratory: shallow, rapidCardiac: dysrrhythmia, ischemia, tachycardiaNeurologic: decrease statusRenal:failureHepatic:decrease met. of meds and wasteHematologic:DICGastrointestinal: Ischemia, increase risk infection
33 Nursing Care in Progressive Stage Usually care for in ICU (increased monitoring)Preventing complicationsPromote comfort and restSupport family members
34 Irreversible Stage Individual in not responding to treatment. Renal and hepatic failure lead to release of necrotic tissue toxins
35 Nursing Care in Irreversible Stage Similar to progressive stageBrief explanations to patientSupportive presence for patient and significant others.In collaboration with significant stakeholders, discuss end of life wishes/decisions.
41 Hypovolemic Shock Decreased intravascular volume due to fluid loss What is a primary example
42 Nursing Care in Hypovolemic Shock PreventionFluid and blood administrationMonitor for cardiac overload and pulmonary edemaMonitor vital signsI&OTemperatureLung soundsCardiac rhythm and rate.
43 Cardiogenic Shock Heart’s ability to contract and pump is impaired General managementCorrect causeAdminister oxygenControl chest painMonitor hemodynamic status
44 Nursing Care in Cardiogenic Shock PreventionMonitor hemodynamic statusAdminister IV fluids and medicationsPromote safety and comfort
45 Distributive Shock Blood is abnormally placed in the vasculature Septic - wide spread infection. Number one cause of death in ICUNeurogenicAnaphylactic
46 Nursing Care in Septic Shock Hyperdynamic phaseHypodynamic phaseID site and source of infectionAntipyretic if T >40Monitor response to medicationsComfort measuresOxygen needs
47 Nursing Care in Neurogenic Shock Results from loss of sympathetic toneSpinal cord injurySpinal anesthesiaNervous system damagePreventative: elevate head 30 degreesSupport CV and neuro functionsElastic stockingsElevate head of bedCheck Homan’s signPassive ROM
48 Nursing Care in Anaphylactic Shock Systemic antigen-antibody reactionPrevention: assess for allergies and observe response to new medications/ blood administrationRemove causative agentSupport cardiac and pulmonary systems